Robert A. Applebaum, Margaret N. Harrigan and Peter Kemper

Mathematica Policy Research

May 1986

This report was prepared under contract #HHS-100-80-0157 between the U.S. Department of Health and Human Services (HHS), Office of Social Services Policy (now known as the Office of Disability, Aging and Long-Term Care Policy) and Mathematica Policy Research, Inc. Additional funding was provided by the Health Care Financing Administration and the Administration on Aging. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The DALTCP Project Officer was Robert Clark.

The channeling demonstration was an intradepartmental long term care initiative funded by the Health Care Financing Administration (HCFA), Administration on Aging (AoA), and the Assistant Secretary for Planning and Evaluation (ASPE).

Over the past decade and a half, a series of demonstrations in addition to channeling have been fielded to test some form of case managed, community-based long term care. After a comprehensive review of these studies, we identified 14 community care demonstrations funded through federal government waivers which had interventions and research designs most relevant to the channeling demonstration. The purpose of this supplementary report is to facilitate comparisons of the interventions, evaluation designs, and estimated effects of these 14 demonstrations with one another and with the two models of channeling.

The demonstrations and the sources from which we draw the information appearing in the remaining tables of the report are presented in Table 1. Differences in methodology, level of detail with respect to the presentation, as well as differences in the treatment and evaluation designs themselves, make it impossible to produce completely comparable table entries.1 In addition, some of the reports from which the tables are compiled were in draft form and may be superceded in the future. Even if these problems did not exist, it still would be a matter of some judgment which specific variables and estimates best reflect in summary form outcomes which were typically measured differently across demonstrations.

For all these reasons, the point estimates appearing in these tables and the absolute differences among them should be interpreted with caution. However, we have used our best judgment about which estimates to display; and we believe that the basic direction of effects and relative differences indicated by the estimates shown are reliable indications of the differences among the demosntrations.

NOTES

Berkeley Planning Associates (1985) made this task somewhat easier with their cross-demosntration study, but only a subset of the demonstrations was included in that work.

LIST OF TABLES

TABLE 1. Prior Community Care Demonstrations and Sources Used for Report

TABLE 1. Prior Community Care Demonstrations and Sources Used for Report

Demonstration(evaluation period)

Source

RANDOMIZED DESIGN

Worcester Home Care (1973-1975)

Commonwealth of Massachusetts. "Final Report, Home Care : An Alternative to Institutionalization." Boston, MA: The Commonwealth of Massachusetts, Department of Elder Affairs, 1975. See also Sherwood, Sylvia, John N. Morris, and Claire E. Gutkin. "Final Report Concerning the Impact of Services on Health and Well-Being." Boston, MA: Department of Social Gerontological Research, Hebrew Rehabilitation Center for the Aged, 1975.

NCHSR Day Care/Homemaker Experiment (1975-1977)

Weissert, William G., Thomas T.H. Wan, and Barbara B. Livieratos. "Effects and Costs of Day Care and Homemaker Services for the Chronically Ill: A Randomized Experiment." Washington, DC: U.S. Department of Health, Education and Welfare, Office of Health Research, Statistics, and Technology, National Center for Health Services Research (Publication No. PHS 79-3258), February 1980.

Allied Home Health Association. "Long Term Care Demonstration Project of North San Diego: Final Report." Washington, DC: U.S. Department of Health and Human Services, Health Care Financing Administration, April 15, 1984.

Maximum of 75 percent of the average of the Medicaid ICF and SNF rates

Yes

18 years or overService need; at risk measured by nursing home preadmission screenMedicaid-eligible (Phase I)

On Lok (1979-1983)

Expanded servicesb

No

No

55 years or overEligible for nursing home placement as measured by need for 24-hour nursingNursing-home certifiable

MSSP (1980-1983)

Expanded services

Maximum of 70 percent of the Medicaid SNF rate

No

Medicaid-eligible65 years or overAt risk of nursing home placement as measured by:Nursing home placement or applicationRecent hospitalizationOver 75Mental disorientation or loss of major caregiver

Nursing Home Without Walls (1980-1983)

Expanded services

Maximum of 75 percent of the average of the Medicaid ICF and SNF rates

No

No age requirementEligible for nursing home placement based on New York state nursing home preadmission assessment instrument (not actual applicant)

New York City Home Care (1980-1983)

Expanded services

No

No

Medicare, Part B65 years or overAt risk measured by functional criteria

These demonstrations also included second generation projects which altered the original interventions. For example, ACCESS received a Medicare waiver to serve a broader target group in its second generation. The Access waiver also allowed the project to reimburse nursing homes at a higher rate in cases of high care clients awaiting hospital discharge without other options.

On Lok also included authorization for institutional long term care services.

NOTE: Receipt of direct services is defined as receipt of a formal service which is arranged and paid for by the project. For channeling, it was defined as completing the initial care plan. Some comparisons across projects are potentially misleading because some projects were designed to rely on existing programs before spending project funds, while others (including the channeling financial control model) were to use project funds for all services.

Includes a range of services such as linen service, various types of respite care, housing assistance, legal assistance, nutrition counseling, and foster care.

Some comparisons across projects are potentially misleading because some projects were designed to rely on existing programs before spending project funds, while others (including the channeling financial control model) were to use project funds for all services. Dollar amounts are converted to constant dollars for the first quarter of 1984, using the GNP implicit price deflator.

Georgia AHS offered these services in-home and in alternative living arrangements such as personal care homes.

Project OPEN also paid deductibles and copayments on these services.

In a second phase, ACCESS added funds to pay nursing homes for high care hospital patients.

On Lok expenditures include all long term services in both community and institutions.

Channeling data are percent of total project expenditures for the service rather than percent of clients receiving the service.

Caregivers of treatment group members reported significantly higher life quality and fewer limitations on privacy and social lives at 6 months

-- Financial Control Model

Type and amount of informal care received

No differences in number of visits received or hours of care from primary caregivers. Reductions (significant at 6 or 12 months or both) in the percent receiving care from visiting caregivers and from friends and neighbors, or relatives other than spouses or children; and in the percent receiving help with housework/laundry/shopping, meal preparation, money management, delivery of prepared meals, transportation, and general supervision.Increases in the percent receiving help with medical treatments (significant at 6 months).

Caregivers of treatment group members reported higher life quality (significant at 6 and 12 months), greater satisfaction with service arrangements (significant at 6 and 12 months), and greater confidence in receipt of care (significant at 6 months).

NONRANDOMIZED DESIGN

Triage (1976-1979)

--

--

ACCESS (1977-1980)

--

--

On Lok (1979-1983)

--

--

MSSP (1980-1983)

--

--

Nursing Home Without Walls (1980-1983)

--

--

New York City Home Care (1980-1983)

Availability of caregivers

No difference

Type and amount (days per week) of informal assistance for ADL and IADL tasks

Treatment group members of subgroup with higher level of informal support at baseline had more informal help with ADL tasks -- significant at 6 and 12 months; treatment group members of subgroup with lower level of impairment received less informal help with IADL tasks -- significant at 6 months.

Type and amount of informal assistance for ADL and IADL tasksa

Treatment group members had more days of informal help with ADL tasks -- significant at 12 months; treatment group members in subgroup with low impairment had fewer days of informal help with IADL tasks -- significant at 12 months.

Results reported are from the final report of Berkeley Planning Associates, 1985.

TABLE 9. Nursing Home and Hospital Use During the 12 Months Following Enrollment

Demonstration(evaluation period)

Nursing Home Use

Hospital Use

Percentage Admitted

Number of Daysa

Percentage Admitted

Number of Daysa

Treatment Group Mean

Nonprogram Group Mean

Treatment Group Mean

Nonprogram Group Mean

Treatment Group Mean

Nonprogram Group Mean

Treatment Group Mean

Nonprogram Group Mean

RANDOMIZED DESIGN

Worcester Home Care (1973-1975)b

--

--

49

50

--

--

4

4

NCHSR Day Care/Homemaker Experiment (1975-1977)c

-- Day care-- Homemaker-- Combined

------

------

534

745

------

------

111615

121616

Georgia AHS (1977-1980)

15

16

22

29

--

--

6

4

Wisconsin CCO (1978-1980)d

15

16

25

33

11*

17

3*

12

Project OPEN (1980-1983)e,f

4

5

.1

.3

19

26

9

12

South Carolina LTC (1980-1984)

42*

58

90*

130

44

39

18

20

Florida Pentastar (1981-1983)g

8

8

--

--

--

--

--

--

San Diego LTC (1981-1983)c

--

--

.5

.9

46

46

9

10

Channeling (1982-1984)f,h

-- Basic Model-- Financial Model

811

1111

2926

3230

3639

3638

1926

2027

NONRANDOMIZED DESIGN

Triage (1976-1979)e,j

10

4

6

4

37

21

8

6

ACCESS (1977-1980)l

--

--

--

--

--

--

--

--

On Lok (1979-1983)j,k

49

56

20*

117

20

57

6

8

MSSP (1980-1983)j,l

--

--

39

22

--

--

20

9

Nursing Home Without Walls (1980-1983)l

-- Upstate Project-- New York City Project

----

----

6*5*

9940

----

----

1918

1616

New York City Home Care (1980-1983)l

7

7

--

--

39

42

11

15

Estimates of number of days are from the final report of the Berkeley Planning Associates 1985 for Project OPEN, San Diego, on On Lok.

Worcester Home Care estimates are converted to days from mean percent of time institutionalized (or hospitalized) which was reported.

San Diego LTC and NCHSR day care/homemaker results are based on Medicare data.

Wisconsin measured outcomes over a 14-month period using only Medicaid data. The 14-month unadjusted figures for percent admitted are reported. Number of days have been prorated to 12 months.

For Project OPEN and Triage, nursing home days include skilled facility days only.

For Project OPEN and channeling, percent admitted to a hospital or a nursing home are for the 6-12 month period.

Florida Pentastar data on percent admitted are for the 1-18 month period.

Channeling estimates of days are the sum of estimates for the first and second six months after randomization for those alive at the beginning of the period.

Standard comparisons were not made for the Access project; rather the study compared Medicaid costs in Monroe County to six comparison counties. Medicaid costs for nursing homes rose 5.7 percent in Monroe County compared to 26.8 percent for the six comparison counties between 1976 and 1980, suggesting nursing home placement may have been reduced. Hospital expenditures increased 36.3 percent from 1976 to 1980 in Monroe County as compared with 37 percent in the six comparison counties.

No statistical tests were reported.

On Lok data on percent admitted are for the 1-24 month period.

For MSSP and Nursing Home Without Walls, days are average per month for one year period multiplied by 12.

* Different from zero statistically at the 5 percent significance level, using a two-tail test.

TABLE 10. Physician and Other Medical Service Expenditures(dollars per month)

Demonstration(evaluation period)

Physician Expenditures

Outpatient Expenditures

Other Expenditures

Treatment Group Mean

Nonprogram Group Mean

Treatment Group Mean

Nonprogram Group Mean

Treatment Group Mean

Nonprogram Group Mean

RANDOMIZED DESIGN

Worcester Home Care (1973-1975)

--

--

--

--

--

--

NCHSR Day Care/Homemaker Experiment (1975-1977)

--

--

--

--

--

--

Georgia AHS (1977-1980) (Medicare and Medicaid)

29

47

10

10

29a

26a

Wisconsin CCO (1978-1980) (Medicaid)

--

--

569b

740b

212c

263c

Project OPEN (1980-1983)

--

--

--

--

--

--

South Carolina LTC (1980-1984)

89

61

25

9

231c

179c

Florida Pentastar (1981-1983)

--

--

--

--

--

--

San Diego LTC (1981-1983)

--

--

--

--

--

--

Channeling (1982-1984)d

-- Basic Model-- Financial Model

102138

97136

----

----

4758

43e56e

NONRANDOMIZED DESIGN

ACCESS (1977-1980)

--

--

--

--

--

--

Triage (1976-1979)

45

21

8

2

60

24

On Lok (1979-1983)

--

--

--

--

--

--

MSSP (1980-1983)

--

--

--

--

--

--

Nursing Home Without Walls (1980-1983)

-- Upstate-- New York City

----

----

----

----

----

----

New York City Home Care (1980-1983)

--

--

--

--

--

--

NOTE: All dollar amounts are converted to constant dollars for the first quarter of 1984, using the GNP implicit price deflator. Time periods to which the original cost data apply are shown in Table 16.

Drugs and Other.

Physician and outpatient.

Drugs.

Channeling estimates include services covered by Medicaid and Medicare and estimated deductibles and coinsurance associated with them.

Treatments more confident and satisfied with care arrangements at 6 and 12 months -- significant both time periods

-- Financial Control Model

Unmet need index (8 item)

Treatments with fewer unmet needs at 6 and 12 months -- significant both time periods

Physical environment checklist (6 item)

No differences

Confidence and satisfaction with receipt of care

Treatments with more confidence and satisfaction with care arrangements at 6 and 12 months -- significant both time periods

NONRANDOMIZED DESIGN

Triage (1976-1979)

--

--

ACCESS (1977-1980)

--

--

On Lok (1979-1983)

--

--

MSSP (1980-1983)

--

--

Nursing Home Without Walls (1980-1983)

--

--

New York City Home Care (1980-1983)

Unmet ADL needs

Treatments with fewer unmet needs at 6 months -- significant

Unmet IADL needs

Treatments with fewer unmet needs at 6 and 12 months -- significant

Unmet medical needs

Treatments with fewer unmet needs at 6 and 12 months -- significant

Physical environment (16 items)

Treatments with few problems with physical environment at 6 and 12 months -- significant

Berkeley PlanningaDependence in ADL and inadequate informal help

Treatments with more unmet needs at 6 and 12 months -- significant

Dependence in IADL and inadequate informal help

Treatments with more unmet needs at 6 and 12 months -- significant

These measures were constructed by Berkeley Planning Associates in the context of measuring substitution of formal for informal care. For example, one of the categories of unmet needs was the presence of formal care (which was taken to imply that the available informal care was inadequate).

Treatments significantly more disabled at 12 monthsTreatments significantly less disabled at 18 months

Restricted Days

Treatments reporting lower number of restricted days -- significant at 6 months

Channeling (1982-1984)

-- Basic Model

ADL (Katz)

No differences

IADL

No differences

Restricted days

Treatments with fewer restricted days at 6 months -- significant

-- Financial Control Model

ADL (Katz)

Treatments more disabled at 6 and 12 months -- significant both time periods

IADL

No differences

Restricted days

No differences

NONRANDOMIZED DESIGN

ACCESS (1977-1980)

--

--

Triage (1976-1979)

ADL (Katz)

No differences

IADL

No differences

On Lok (1979-1983)

ADL (measure not known)

No differences

IADL

Treatments less impaired at 12 months -- significant

MSSP (1980-1983)

ADL (Katz)

No differences

IADL

Treatments less impaired at 6 months -- significant

Nursing Home Without Walls (1980-1983)

ADL (Katz)

Treatments less disabled at 6 and 12 months -- significant for New York City sample

New York City Home Care (1980-1983)

ADL (Katz)b

Treatments significantly more disabled at 12 months

IADL

Treatments significantly mroe impaired at 12 months

The Katz measure was originally developed to be completed by clinicians (Katz et al. 1970). However, in most studies a self-reported measure asking whether the individual does perform the task was used. The OARS in contrast asks capacity, whether the respondent can perform the task.

In these two studies both clinical observation and self-report measures were used, and no major differences in results were reported for the two approaches (personal communication, Capitman, October 1985).

Channeling cost estimates differ from estimates persented elsewhere. For comparability with estimates available for other demonstrations, channeling case management costs have been divided by all months clients spent in channeling. They include reported in-kind costs and demonstration-related costs. Other estimates are based on Berkeley Planning Associates (1985) and have been converted to 1984 dollars. See Thornton, Will, and Davies. The Evaluation of the National Long Term Care Demonstration: Analysis of Channeling Project Costs. Table VI.1. [Executive Summary]

NOTE: Costs per month were calculated by dividing costs reported for the time period by the number of months in the time period. All dollar amounts are converted to constant dollars for the first quarter of 1984, using the GNP implicit price deflator. Detail may not sum to total due to rounding.

Includes case management and formal community services, wherever available. In the case of channeling, this column also includes room and board in the community.

Project costs are understated and Medicare costs overstated by the costs of services received when a client was assigned to both services but received only one.

Data came from the final report of Berkeley Planning Associates, 1985. The data from Project OPEN's final report (Skiar and Weiss, 1983) show treatments to have lower total costs, however.

The Pentastar project reported the costs of the initial assessment for the control group members as project services for controls.

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